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As the evolving changes in healthcare continue to lead to increased scrutiny of the quality of patient care and cost controls, hospitals are searching for ways to improve discharge planning and transition management as a means to lower readmissions rates. Because transition management is a core competency of a successful and effective hospitalist practice, hospitalists can play a pivotal role in carrying out effective discharge planning and post-discharge follow-up that contribute to reduced readmissions.
Hospitalists use a number of strategies to ensure a patient's safe transition during the unsupervised, potentially dangerous period between hospital discharge and the first appointment with a primary care physician or placement in a post-acute facility.
 Communication is vital for transition management
The first step in lowering readmissions actually begins when the patient is admitted. Effective clinical communication -- beginning at admission and continuing right through to discharge -- is central to effective transition management. The patients' doctors, nurses and case managers should have regular multidisciplinary meetings to discuss any issues they need to focus on -- not only during the patient's course of treatment, but before discharge.
From the onset hospitalists should be communicating and working with patients, their families and other providers (including PCPs, specialists, physicians in a post-acute care facility) to identify goals, and discuss discharge plans and follow-up care. Patients and their families (or caregivers) can be overwhelmed by follow-up care instructions. It is, therefore, imperative to ensure they have a complete understanding of the hospitalists' discharge instructions so the patient's condition can be properly managed after he or she leaves the hospital. They also need to know who they should contact if they have any medical problems after being discharged, especially during the first 5 days he or she leaves the hospital. Sharing information ensures that everyone is aligned, improving the transition of care and, ultimately, reducing the risk of readmission.
Technology boosts patient safety and outcomes
Clinical communications technology designed for hospitalists to improve patient safety and outcomes can boost transition management. For example, most congestive heart failure patients should be discharged with a prescription for an ACE inhibitor. To prevent this from being overlooked at the time of discharge, automatic reminders should pop-up as the physician is writing up the paperwork.
All involved parties -- primary care physician, specialists on the case, post-acute care physicians, etc. -- should receive timely communication regarding the patient's discharge, ideally within an hour.
Post discharge follow-up is essential to ensuring patient compliance with their doctor's discharge program. Patients inadvertently jeopardize their recovery and end up going back to the hospital for a variety of reasons. For example, patients don't take their medicine -- either because they forgot, didn't understand instructions or didn't pick up important prescriptions. They might not have transportation for follow-up care, or their post-acute care facility might not have been appropriate for their needs. And the cycle starts again.
A post-discharge call center that contacts patients within 48-72 hours after discharge to check they aren't experiencing any unexpected symptoms, they have the necessary medications and they have made follow-up appointments, is vital to helping prevent readmissions. In addition to determining the patient's general outcome and answering questions, call centers should use "smart" surveys customized to a particular patient's situation that ask specific questions related to the patient's care. For instance, if a patient was discharged on an anti-coagulant, the survey would include a question about the patient's knowledge of the need for close monitoring to avoid complications.
There is no substitute for a discharge note
The value of a clear and concise discharge note in effective transition management cannot be emphasized enough. Without it, a patient's primary care physician and/or physician at a post-acute facility would be in the dark about the patient's hospitalization.
Discharge notes should be tailored to the level of care the patient is being transferred to and directed to the provider or physician in the place where the patient is being handed off (home, rehabilitation facility, skilled nursing facility, etc.). The documentation information in the discharge note should focus upon the essence of the patient's hospitalization, status, medications, other appropriate clinical data and what the loose ends are; i.e., what does that doctor need to do soon after the patient's discharge to help ensure the patient's recovery.
Reducing readmissions is possible
When properly implemented, effective discharge planning and transition management can prevent the vicious cycle of bouncebacks to the hospital -- maximizing scarce healthcare resources, saving money and preventing patients from suffering needlessly.
 Kerry Weiner, MD, is chief clinical officer of North Hollywood, California-based IPC The Hospitalist Company Inc., a leading national physician group practice company.
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